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CHAPTER 79: Tetanus

KEY POINTS

Tetanus is caused by Clostridium tetani and is a toxin-mediated disease.

Although rare in the USA, worldwide there are between 500,000 and 1 million cases a year, with over 200,000 deaths.

It characterized by trismus, dysphagia, and localized muscle rigidity near a site of injury, often progressing to severe generalized muscular spasms complicated by respiratory failure and cardiovascular instability.

The diagnosis of tetanus is made on clinical grounds alone. A clinical diagnosis of presumed tetanus is sufficient to initiate treatment.

Patients with tetanus should be managed in an ICU. In severe cases, the first priority is control of the airway to ensure adequate ventilation and correction of hypotension related to hypovolemia and/or autonomic instability.

Antitoxin therapy with human tetanus immune globulin is given intramuscularly (500-3000 IU) as early as possible.

Treatment to limit continued production and absorption of toxin includes surgical debridement of the site of injury and antimicrobial therapy with intravenous metronidazole.

Traditionally muscle rigidity and spasms have been treated with high-dose benzodiazepines and narcotics. However, intravenous magnesium therapy should also be considered.

Cardiovascular instability due to autonomic dysfunction is managed by ensuring normovolemia and using benzodiazepine, narcotic, and/or magnesium sulfate infusions when needed.

Tetanus is often a disease of otherwise healthy active people. Fully developed tetanus is frequently rapidly fatal unless the patient is supported through a lengthy period of painful muscle spasms complicated by respiratory failure, cardiovascular instability, and increased risk of pulmonary embolism and nosocomial infection. In developed countries, this disease is likely to remain an uncommon but challenging problem that demands an alert and aggressive approach to initial diagnosis and management. If this early management is coupled with attentive supportive care and avoidance of complications over a period of prolonged critical illness, excellent outcomes are possible in most cases.

EPIDEMIOLOGY

Historically, tetanus was a feared complication of wound infections. This Clostridium tetani toxin-mediated disease is one of several toxin-mediated diseases resulting from wound infections, along with staphylococcal and streptococcal toxic shock syndrome, wound botulism, and wound diphtheria. Since the advent of routine vaccination after trauma injury and passive immunization for grossly contaminated wounds, tetanus has become uncommon in the United States with an average of 43 cases annually from 1998 to 2000.1 Worldwide it is still a major cause of morbidity and mortality, and remains one of the WHO targeted diseases. Overall, 500,000 to 1 million cases occur worldwide each year, with 213,000 deaths, the majority in children less than 5 years of age. This is mainly due to inadequate vaccination, either because of access to care or neonatal infections before vaccination is ...